D

DBQ Initial Evaluation of Residuals of Traumatic Brain Injury (I-TBI) Disability¹

Name of Patient/Veteran: ________________________________SSN: __________________ Your patient is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits.

VA will consider the information you provide on this questionnaire as part of their evaluation in processing the Veteran’s claim.

SECTION I

1. Diagnosis

Does the Veteran now have or has he/she ever had a traumatic brain injury (TBI) or any residuals of a TBI?

Yes No

If yes, select the Veteran’s condition (check all that apply):

Traumatic brain injury (TBI) ICD code: _________ Date of diagnosis: _____

Other diagnosed residuals attributable to TBI, specify: _________

Other diagnosis #1: _________

ICD code: _________

Date of diagnosis: _________

Other diagnosis #2: _________

ICD code: _________

Date of diagnosis: _________

Other diagnosis #3: _________

ICD code: _________

Date of diagnosis: _________

Other diagnosis #4: _________

ICD code: _________

Date of diagnosis: ______________

___________________

¹ Published by the Department of Veterans Affairs. See https://www.dcms.uscg.mil/Portals/10/CG1/PSC/PSD/docs/VBA%20-%20Initial%20evaluation%20of%20TBI%20residuals.pdf?ver=2017-03-28-105323-973 (accessed December 28, 2018).

If there are additional diagnoses that pertain to the residuals of a TBI, list using above format: ______________

2. Medical history

1. Describe the history (including onset and course) of the Veteran’s TBI and residuals attributable to TBI (brief summary): ______________________________________
2. Was the Veteran exposed to any blasts?

   Yes No

   If yes, indicate number of blasts:

   1 2 3 More than 3

   Date of first blast exposure: _______________

   Date of last blast exposure: _______________

   How many blasts were severe enough to knock Veteran down or cause injury?

   0 1 2 3 More than 3

3. Does the Veteran’s treatment plan include taking continuous medication for the diagnosed condition?

   Yes No

   If yes, list only those medications used for the diagnosed condition: _________________

3. Evidence review

Was medical evidence available for review as part of this examination?

Yes No

If yes, indicate evidence reviewed as part of this examination (check all that apply):

VA claims file (C-file)

If checked, documents listed separately below that are included in a C-file do not need to be additionally indicated.

Veterans Health Administration medical records (CPRS treatment records)

Civilian medical records

Military service treatment records

Military service personnel records

Military enlistment examination

Military separation examination

Military post-deployment questionnaire

Department of Defense Form 214 separation document

Previous disability decision letters

Correspondence and non-medical documents related to condition

Interviews with collateral witnesses (family and others who have known the Veteran before and after military service)

Medical evidence brought to exam by Veteran

If checked, describe: ___________________

Other, describe: ______________________________________

SECTION II. Assessment of cognitive impairment and other residuals of TBI

NOTE: For each of the following 10 facets of TBI-related cognitive impairment and subjective symptoms (facets 1–10 below), select the ONE answer that best represents the Veteran’s current functional status.

Neuropsychological testing may need to be performed in order to be able to accurately complete this section. If neuropsychological testing has been performed and accurately reflects the Veteran’s current functional status, repeat testing is not required.

1. Memory, attention, concentration, executive functions

No complaints of impairment of memory, attention, concentration, or executive functions.

A complaint of mild memory loss (such as having difficulty following a conversation, recalling recent conversations, remembering names of new acquaintances, or finding words, or often misplacing items), attention, concentration, or executive functions, but without objective evidence on testing.

Objective evidence on testing of mild impairment of memory, attention, concentration, or executive functions resulting in mild functional impairment.

Objective evidence on testing of moderate impairment of memory, attention, concentration, or executive functions resulting in moderate functional impairment.

Objective evidence on testing of severe impairment of memory, attention, concentration, or executive functions resulting in severe functional impairment.

If the Veteran has complaints of impairment of memory, attention, concentration or executive functions, describe (brief summary):
______________________________________________

2. Judgment

Normal

Mildly impaired judgment. For complex or unfamiliar decisions, occasionally unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision.

Moderately impaired judgment. For complex or unfamiliar decisions, usually unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision, although has little difficulty with simple decisions.

Moderately severely impaired judgment. For even routine and familiar decisions, occasionally unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision.

Severely impaired judgment. For even routine and familiar decisions, usually unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision. For example, unable to determine appropriate clothing for current weather conditions or judge when to avoid dangerous situations or activities.

If the Veteran has impaired judgment, describe (brief summary): ___________________

3. Social interaction

Social interaction is routinely appropriate.

Social interaction is occasionally inappropriate.

Social interaction is frequently inappropriate.

Social interaction is inappropriate most or all of the time.

If the Veteran’s social interaction is not routinely appropriate, describe (brief summary):

4. Orientation

Always oriented to person, time, place, and situation.

Occasionally disoriented to one of the four aspects (person, time, place, situation) of orientation.

Occasionally disoriented to two of the four aspects (person, time, place, situation) of orientation or often disoriented to one aspect of orientation.

Often disoriented to two or more of the four aspects (person, time, place, situation) of orientation.

Consistently disoriented to two or more of the four aspects (person, time, place, situation) of orientation.

If the Veteran is not always oriented to person, time, place, and situation, describe (brief summary): _______

5. Motor activity (with intact motor and sensory system)

Motor activity normal.

Motor activity is normal most of the time, but mildly slowed at times due to apraxia (inability to perform previously learned motor activities, despite normal motor function).

Motor activity is mildly decreased or with moderate slowing due to apraxia.

Motor activity moderately decreased due to apraxia.

Motor activity severely decreased due to apraxia.

If the Veteran has any abnormal motor activity, describe (brief summary): ______

6. Visual spatial orientation

Normal

Mildly impaired. Occasionally gets lost in unfamiliar surroundings, has difficulty reading maps or following directions. Is able to use assistive devices such as GPS (global positioning system).

Moderately impaired. Usually gets lost in unfamiliar surroundings, has difficulty reading maps, following directions, and judging distance. Has difficulty using assistive devices such as GPS (global positioning system).

Moderately severely impaired. Gets lost even in familiar surroundings, unable to use assistive devices such as GPS (global positioning system).

Severely impaired. May be unable to touch or name own body parts when asked by the examiner, identify the relative position in space of two different objects, or find the way from one room to another in a familiar environment.

If the Veteran has impaired visual spatial orientation, describe (brief summary): _______

7. Subjective symptoms

No subjective symptoms.

Subjective symptoms that do not interfere with work; instrumental activities of daily living; or work, family or other close relationships. Examples are: mild or occasional headaches, mild anxiety.

Three or more subjective symptoms that mildly interfere with work; instrumental activities of daily living; or work, family or other close relationships. Examples of findings that might be seen at this level of impairment are: intermittent dizziness, daily mild to moderate headaches, tinnitus, frequent insomnia, hypersensitivity to sound, hypersensitivity to light.

Three or more subjective symptoms that moderately interfere with work; instrumental activities of daily living; or work, family or other close relationships. Examples of findings that might be seen at this level of impairment are: marked fatigability, blurred or double vision, headaches requiring rest periods during most days.

If the Veteran has subjective symptoms, describe (brief summary): ______

8. Neurobehavioral effects

NOTE: Examples of neurobehavioral effects of TBI include: irritability, impulsivity, unpredictability, lack of motivation, verbal aggression, physical aggression, belligerence, apathy, lack of empathy, moodiness, and lack of cooperation, inflexibility, and impaired awareness of disability. Any of these effects may range from slight to severe, although verbal and physical aggression are likely to have a more serious impact on workplace interaction and social interaction than some of the other effects.

No neurobehavioral effects.

One or more neurobehavioral effects that do not interfere with workplace interaction or social interaction.

One or more neurobehavioral effects that occasionally interfere with workplace interaction, social interaction, or both but do not preclude them.

One or more neurobehavioral effects that frequently interfere with workplace interaction, social interaction, or both but do not preclude them.

One or more neurobehavioral effects that interfere with or preclude workplace interaction, social interaction, or both on most days or that occasionally require supervision for safety of self or others.

If the Veteran has any neurobehavioral effects, describe (brief summary): ______

9. Communication

Able to communicate by spoken and written language (expressive communication) and to comprehend spoken and written language.

Comprehension or expression, or both, of either spoken language or written language is only occasionally impaired. Can communicate complex ideas.

Inability to communicate either by spoken language, written language, or both, more than occasionally but less than half of the time, or to comprehend spoken language, written language, or both, more than occasionally but less than half of the time. Can generally communicate complex ideas.

Inability to communicate either by spoken language, written language, or both, at least half of the time but not all of the time, or to comprehend spoken language, written language, or both, at least half of the time but not all of the time. May rely on gestures or other alternative modes of communication. Able to communicate basic needs.

Complete inability to communicate either by spoken language, written language, or both, or to comprehend spoken language, written language, or both. Unable to communicate basic needs.

If the Veteran is not able to communicate by or comprehend spoken or written language, describe (brief summary): ___________________________

10. Consciousness

Normal

Persistent altered state of consciousness, such as vegetative state, minimally responsive state, coma.

If checked, describe altered state of consciousness (brief summary):

SECTION III

1. Residuals

Does the Veteran have any subjective symptoms or any mental, physical, or neurological conditions or residuals attributable to a TBI (such as migraine headaches or Meniere’s disease)?

Yes No

If yes, check all that apply:

Motor dysfunction

If checked, ALSO complete specific Joint or Spine Questionnaire for the affected joint or spinal area.

Sensory dysfunction

If checked, ALSO complete appropriate Cranial or Peripheral Nerve Questionnaire.

Hearing loss and/or tinnitus

If checked, ALSO complete a Hearing Loss and Tinnitus Questionnaire.

Visual impairment

If checked, ALSO complete an Eye Questionnaire.

Alteration of sense of smell or taste

If checked, ALSO complete a Loss of Sense of Smell and Taste Questionnaire.

Seizures

If checked, ALSO complete a Seizure Disorder Questionnaire.

Gait, coordination, and balance

If checked, ALSO complete appropriate Questionnaire for underlying cause of gait and balance disturbance, such as Ear Questionnaire.

Speech (including aphasia and dysarthria)

If checked, ALSO complete appropriate Questionnaire.

Neurogenic bladder

If checked, ALSO complete appropriate Genitourinary Questionnaire.

Neurogenic bowel

If checked, ALSO complete appropriate Intestines Questionnaire.

Cranial nerve dysfunction

If checked, ALSO complete a Cranial Nerves Questionnaire.

Skin disorders

If checked, ALSO complete a Skin and/or Scars Questionnaire.

Endocrine dysfunction

If checked, ALSO complete an Endocrine Conditions Questionnaire.

Erectile dysfunction

If checked, ALSO complete Male Reproductive Conditions Questionnaire.

Headaches, including Migraine headaches

If checked, ALSO complete a Headache Questionnaire.

Meniere’s disease

If checked, ALSO complete an Ear Conditions Questionnaire.

Mental disorder (including emotional, behavioral, or cognitive)

If checked, ALSO complete Mental Disorders or PTSD Questionnaire.

Other, describe: __________________

If checked, ALSO complete appropriate Questionnaire.

2. Other pertinent physical findings, scars, complications, conditions, signs and/or symptoms

1. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis section above?

   Yes No

   If yes, are any of the scars painful and/or unstable, or is the total area of all related scars greater than 39 square cm (6 square inches)?

   Yes No

   If yes, also complete a Scars Questionnaire.

2. Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms?

   Yes No

   If yes, describe (brief summary): _________________________

3. Diagnostic testing

NOTE: If diagnostic test results are in the medical record and reflect the Veteran’s current TBI residuals, repeat testing is not required.

1. Has neuropsychological testing been performed?

   Yes No

   If yes, provide date: _________________________

   Results: ___________________________________

2. Have diagnostic imaging studies or other diagnostic procedures been performed?

   Yes No

   If yes, check all that apply:

   Magnetic resonance imaging (MRI)

   Date: ___________ Results: ______________

Computed tomography (CT)

Date: Results:

___________ ______________ EEG

Date: ___________ Results: ______________

Other, describe:

Date: ___________ Results: ______________

• Has laboratory testing been performed?

Yes No

If yes, specify tests: Date: ___________ Results: ______________

• Are there any other significant diagnostic test findings and/or results?

Yes No

If yes, provide type of test or procedure, date and results (brief summary): ___________

4. Functional impact

Do any of the Veteran’s residual conditions attributable to a traumatic brain injury impact his or her ability to work?

Yes No

If yes, describe impact of each of the Veteran’s residual conditions attributable to a traumatic brain injury, providing one or more examples: _____________________

5. Remarks, if any:

______________________________________________________________

Physician signature: __________________________________________ Date: _____________

Physician printed name: _______________________________________

Medical license #: _____________

Physician address: __________________________

Phone: ________________________ Fax: ________________________

NOTE: The VA may request additional medical information, including additional examinations if necessary to complete the VA’s review of the veteran’s application.